For Internal Use Only: Date Received: Tracking Number

QUESTIONNAIRE TO RANK PROJECTS FOR POTENTIAL FINANCIAL ASSISTANCE THROUGH THE DRINKING WATER STATE REVOLVING FUND (DWSRF) PROGRAM NORTH DAKOTA DEPARTMENT OF ENVIRONMENTAL QUALITY DIVISION OF MUNICIPAL FACILITIES SFN 54458 (9-2021)

System Information Public Water System (PWS) Name PWS Number

ND Contact Person Telephone Number

Address City State ZIP Code

Consulting Engineering Firm (if any) Engineering Firm Contact Name

Email Telephone Number

Project Information Project Description (attach additional information as needed, including available engineering reports):

Anticipated Start Dates for Project:

Planning: Design: Construction:

FILL OUT QUESTIONNAIRE COMPLETELY AND PROVIDE SUPPORTING DOCUMENTATION WHERE REQUIRED. FAILURE TO DO SO MAY RESULT IN NO POINTS BEING AWARDED.

SFN 55458 (9-2021) Page 2 of 5

Water Quality For any “yes” responses in this section, detailed information concerning water quality problems over the past 4 years and how the project will solve the problems must be provided in an attachment. A. Is one of the purposes of your project to correct ongoing and unresolved water

quality problems that your system is experiencing? Yes No

B. Is one of the purposes of your project to correct ongoing and unresolved waterquality problems experienced by other public water systems (PWSs) throughconsolidation with or regionalized service by your system?

Yes No

C. Is one of the purposes of your project to correct ongoing and unresolved waterquality problems experienced by individual households or businesses (i.e., non-PWSs) that are within your service area (and presently using their own watersupplies) through consolidation with or regionalized service by your system?

Yes No

Water Quantity For any “yes” responses in this section, detailed information concerning the water quantity problems and how the project will solve the problems must be provided in an attachment. Information must include an estimate of the maximum water (in gallons per day) presently available to residential users served by your system or frequency of shortages. A. Is one of the purposes of your project to correct and ongoing and unresolved water

quantity problem that your system is experiencing? Yes No

B. Is one of the purposes of your project to correct ongoing and unresolved waterquantity problems experienced by other PWSs through consolidation with orregionalized service by your system?

Yes No

C. Is one of the purposes of your project to correct ongoing and unresolved waterquantity problems experienced by individual households or businesses (i.e., non-PWSs) that are within your service area (and presently using their own watersupplies) through consolidation with or regionalized service by your system?

Yes No

Infrastructure Adequacy From the list below, indicate which infrastructure problems, if any, that your project is intended to correct (applies to your system only). A complete description of each problem, along with an explanation of how the project will solve the problem, must be attached.

A. Correction of general disinfection treatment deficiencies (excludes improvementsnecessary to directly comply with the different Surface Water Treatment Rules andthe Groundwater Rule).

Yes No

B. Correction of well construction deficiencies. Yes No C. Correction of distribution system pressure problems (dynamic pressure < 20 psi). Yes No D. Replacement of deteriorated water mains and/or service lines. Yes No E. Replacement of deteriorated finished water storage structures. Yes No F. Replacement of distribution system piping/materials and/or service lines shown via

Department approved testing to contribute to unacceptable levels of lead orasbestos.

Yes No

G. Water treatment plant (WTP) operating at or above design capacity. The followinginformation must be attached: design capacity and projected capacity. Yes No

H. WTP operating at or beyond useful or design life. Information documenting the ageand design life of the WTP must be attached. Yes No

I. Correction of specific design or operating deficiencies associated with watertreatment plant unit processes (excludes disinfection treatment). Yes No

J. Correction of specific design or operating deficiencies associated with surface waterintake facilities. Yes No

K. Correction of specific design or operating deficiencies associated with finished waterstorage facilities. Yes No

L. Correction of specific design or operating deficiencies associated with raw orfinished water pumping facilities. Yes No

SFN 55458 (9-2021) Page 3 of 5

M. Correction of specific design or operating deficiencies associated with raw orfinished water distribution system piping. Yes No

N. Correction of specific design or operating deficiencies associated with chemical feedinstallations (excludes disinfection). Yes No

O. For systems relying solely on their own groundwater supply, provision of a secondwell where only one functional well exists. Yes No

P. Replacement of inoperative, obsolete, or inadequate instrumentation or controls. Yes No

Affordability and Project Financial Considerations ALL SYSTEMS

What is the estimated cost of your project (including planning, design, construction, and land costs) $

MUNICIPAL SYSTEMS ONLY A. What is the total population presently served by your system, including the

population of bulk users served by master meter?B. Following project completion, what total population will your system serve, including

the population of bulk users served by master meter?C. How many total service connections does your system presently have? Following

project completion, how many total service connections will your system have?Consider users within your municipality such as individually metered residences,schools, businesses, campgrounds, and rest areas as one service connection.Include the number of residential service connections within bulk users served bymaster meter such as trailer courts and subdivisions. Do NOT include users andassociated service connections that you supply water to OUTSIDE of yourmunicipality (if any).

Present:

Following project completion:

D. For a typical single residential user, what is your present average annual charge forwater service based on a water usage of 5,000 gallons per month? Include, ifapplicable, costs recovered through special assessments.

$ /YEAR

E. As a result of the project, what is your expected average annual charge for waterservice for a typical single residential user based on a water usage of 5,000 gallonsper month? Include, if applicable, costs to be recovered through specialassessments.

$ /YEAR

REGIONAL AND RURAL WATER SYSTEMS ONLY Provide the information requested in Attachment 1.

OPERATOR SAFETY

Is one of the purposes of your project to correct a critical and chronic safety hazard, an intermittent safety hazard, or a potential significant safety hazard for your water system operators? If yes, a detailed description of the safety hazards to be corrected must be attached.

Yes No

MISCELLANEOUS

Is the primary purpose of your project to increase water availability for or to improve fire protection? If yes, a detailed description of these project features must be attached.

Yes No

Lead Service Lines Are any lead service lines present in your system? Yes No If yes, provide your best estimate of the number of: Full lead service lines Partial lead service lines

Will the proposed project include lead service line replacement? Yes No

SFN 55458 (9-2021) Page 4 of 5

Refinance of Existing Debt Does this project involve the refinance of existing debt on a past infrastructure project? Yes No If yes, please fill out the following information: Lender Remaining loan balance Interest rate Remaining loan term in years

Original construction date

Statement of Certification I certify that the above information, to the best of my knowledge, is true and accurate. Signature: Date:

Name (print): Telephone number:

Title:

Please direct this questionnaire to ndsrf@nd.gov or:

NDDEQDWSRF Program

4201 Normandy St. Bismarck, ND 58503-1324

The DWSRF Program can be reached at 701-328-5211.

SFN 55458 (09-2021) Page 5 of 5

ATTACHMENT 1

Pre-Project and Post-Project Service Area Characteristics for Regional and Rural Water Systems

The below information is required to rank projects submitted by regional and rural systems for potential DWSRF loan assistance. A tabular format is preferred for presentation of the information. A narrative format is acceptable as long as the information is condensed and not dispersed within a lengthy document requiring review. Regional and rural water system projects cannot be ranked unless all of the requested information is provided.

The following information must be provided for each county that presently receives water service and will receive service following project completion:

• Population served: provide a breakdown (by user type) of the pre- and post-projectpopulation served. Provide a separate listing of all bulk users and identify thepopulation served by each. Consider systems served by master meter such as trailercourts, subdivisions, municipalities, and other regional rural water systems as bulkusers.

• Service connections: provide a breakdown (by user type) of the pre- and post-projectservice connections. As part of the bulk user listing, identify the number of serviceconnections within each bulk user system.

• Average annual charge for water service: provide a copy of the pre- and post-projectwater rate schedule. Identify the average annual charge for a typical singleresidential/individual user. As part of the bulk user listing, identify the average annualcharge for each bulk user system. Base all average annual charges on a water usageof 5,000 gallons per month.